Smoky Ridge Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Smoky Ridge Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 20, 2024

  Based on record review and resident, Family Member, and staff interviews, the facility failed to protect the resident's right to be free from employee to resident abuse for 1 of 3 residents reviewed for abuse (Resident #1). Nurse #1 reported that Resident #1 hit Nurse Aide (NA) #1 in the face while she was providing care to him. Nurse #1 observed NA #1 grab Resident #1's arm and push it towards his stomach and hold it there while leaning in Resident #1 face and saying, don't you ever hit me again, do you understand?. Three days after the incident Resident #1 was observed to have a small round circular bruise on top of his right forearm and a faded circular bruise on the side of his right forearm. […]

• No harm, potential for more than minimal, widespreadF812Dec 1, 2023

  Based on observations and staff interviews the facility failed to maintain clean ceiling vents located in the dry storage room and in the kitchen, failed to maintain a clean walk-in refrigerator and remove food with signs of spoilage from the walk-in refrigerator. Additionally, the facility failed to clean and maintain 3 of 3 ice makers, and clean and maintain ice cooler scoops and holders (the kitchen ice maker, North and South nourishment room ice makers). This practice had the potential to affect food and beverages served to residents. The findings included: a. On [DATE] at 9:23 AM an observation of a ceiling vent in the dry storage area of the kitchen contained a build up of fluffy debris with spider webs spread across the vent. […]

• No harm, potential for more than minimal, widespreadF867Dec 1, 2023

  Based on observations, record review, and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions previously put in place following a COVID-19 focused survey that occurred 12/04/20. This failure was for one deficiency that was originally cited in the area of Infection Control (F-880) and was subsequently recited on the current recertification and complaint investigation survey of 12/01/23. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. […]

• No harm, potential for more than minimal, widespreadF880Dec 1, 2023

  Based on observations, record review and staff interviews, the facility failed to assess the facility's water system to identify where Legionella and other waterborne pathogens could grow and spread which had the potential to affect 92 of 92 residents. The facility also failed to ensure staff implemented their infection control policies and procedures when Nurse #1 did not place a barrier between the wound care supplies and an overbed table that had crumbs and dried debris on the surface and did not change her gloves after removing a wound dressing and before cleaning the wound for 1 of 1 sampled resident (Resident #54). Findings included: 1. […]

• No harm, potential for more than minimal, patternF641Jun 26, 2026

  Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of falls, medications received, and hospice for 4 of 21 residents reviewed for accuracy of MDS assessments (Resident #12, #7, #9 and #10). Findings included: 1. Resident #12 was admitted to the facility on [DATE]. A nurse's progress note revealed on 5/11/26, Resident #12 was found sitting on the floor beside the bed and reported he tried to get up and fell. Resident #12's vital signs and range of motion were assessed as being within normal limits, there were no visible signs of an injury, and he was assisted back to bed. […]